Premature ejaculation is a male sexual dysfunction characterized by short, easily stimulated ejaculation that occurs always or nearly always before or within one minute of vaginal penetration.
It is involuntarily controlled and causes negative personal consequences like distress, frustration and avoidance of sexual intimacy.
Exact etiology and risk factors are unknown.

Diminishes the sensitivity of the glans penis that may inhibit the spinal reflex arc responsible for ejaculation

Use is well established & is moderately effective in delaying ejaculation

There are evidences of efficacy & effectiveness as off-label on-demand treatment for lifelong PE

Lidocaine-Prilocaine cream applied 20-30 minutes prior to intercourse

Prolonged application (eg 30-45 minutes) may result in the loss of erection due to numbness of the penis

Condom should be worn to avoid diffusion of the topical agent to the vaginal wall that can cause numbness in the partner

Tramadol

Has been investigated as a potential off-label therapy for PE w/ several studies demonstrating efficacy

Should be considered only when other therapies are not effective due to potential risk of addiction & side effects

Further well-controlled studies is needed to assess the efficacy & safety in the treatment of PE

Phosphodiesterase type 5 Inhibitors

Eg Sildenafil, Tadalafil, Vardenafil

Several recent studies supported its therapeutic role but there is only one clinical trial that shows Sildenafil’s role in the treatment of PE

IELT was not significantly improved but Sildenafil increased confidence, perception of ejaculatory control, & overall sexual satisfaction as well as reduced anxiety & decreased refractory time to achieve a second erection after ejaculation

Treatment in men w/ lifelong PE w/ normal erectile function is not recommended & further evidence-based research is encouraged to understand conflicting data

COMBINATION THERAPY

Studies have shown that combination therapy (ie pharmacological therapy was given in conjunction w/ a behavioural treatment) was better than pharmacological therapy alone on either IELT index

Combining a medical & psychological approach may be especially useful in men w/ acquired PE where there is a clear psychosocial precipitant, or lifelong cases where the individual or couple’s issues interfere w/ the medical treatment & success of therapy

Similarly, in men w/ PE & comorbid erectile dysfunction, combination therapy may also be helpful to manage the psychosocial aspects of the sexual dysfunctions

Modern approach to PE treatment

Non-Pharmacological Therapy

Indicated in patients uncomfortable w/ pharmacological therapy

Behavioural techniques are not recommended for first line treatment of lifelong PE

Goals of psychotherapy in men & couples suffering from PE are:

Help men develop sexual skills that will enable them to delay ejaculation while broadening their sexual scripts, increasing sexual self-confidence & diminishing performance anxiety

Focus on resolving psychological & interpersonal issues that may have precipitated, maintained or be the consequence of the PE symptom for the man, partner or couple

Efficacy of psychological & behavioral interventions have some supporting evidence although future well designed studies on the efficacy of psychotherapy are needed

Men w/ natural variable PE should be educated & reassured

Men w/ premature-like ejaculatory dysfunction may require a referral for psychotherapy

Behavioural Strategies

Stop-Start maneuver involves the partner stimulating the man’s penis until the sensation of almost climaxing (inevitable orgasm) is felt & at which time stimulation is abruptly stopped until this feeling disappeared

The partner must repeat this cycle until the ejaculation can be controlled voluntarily

In the Squeeze technique, the partner is advised to squeeze the penile frenulum or glans, just on cessation of penile stimulation at the time of inevitable orgasm, & then the female partner restarts the stimulation at least 30 seconds later

Stop-Start & Squeeze techniques are typically applied in a cycle of three pauses proceeding to orgasm

They focus on distraction & a reduction of excitement or stimulation, that may also detract from overall sexual satisfaction, & are based on the theory that the reason PE occurs is that the man fails to appreciate the sensations of heightened arousal & to recognize the feelings of ejaculatory inevitability

The main goal of traditional psychosexual treatment for PE is to help men identify the premonitory sense of ejaculation/orgasm & work w/ the patient to improve self-control

Masturbation before anticipation of sexual intercourse is the behavioral technique usually used by many younger men

Women with neuropathic bladder (NB) and paediatric lower urinary tract reconstruction (LUTR) are at increased risk of developing complications during pregnancy and caesarean delivery (CD), with those having prolonged labour, prior CD or a history of noncompliance having the worst complications, according to a study.